British Journal of Sports Medicine

British Journal of Sports Medicine

Drifting into unconsciousness: Jason Zirganos and the mystery of undetected hypothermia

19-08-2019 – Tipton, M.

Editorial

Swimming authorities must enforce minimum temperature rules in open water swimming because some open water swimmers—particularly those who are well acclimatised to cold—are unable to judge how cold they are. This potential problem was confirmed in the study of Saycell et al in this issue of British Journal of Sports Medicine.1 Cold habituation from repeated exposure to cold water can produce a ‘hypothermic’ adaptation to cold in which the acclimated individuals lose their perceptual and physiological responses to cooling. They do not shiver as much and paradoxically feel more comfortable as their deep body temperature falls. This was clearly demonstrated in the classic studies of Channel swimmers published in 1955 by Pugh and Edholm.2 Pugh’s investigations of the greatest open water swimmer of his generation, Jason Zirganos (figure 1), showed that, during resting immersions in cold water, Zirganos’ deep body temperature fell more…

Medical encounters (including injury and illness) at mass community-based endurance sports events: an international consensus statement on definitions and methods of data recording and reporting

19-08-2019 – Schwellnus, M., Kipps, C., Roberts, W. O., Drezner, J. A., DHemecourt, P., Troyanos, C., Janse van Rensburg, D. C., Killops, J., Borresen, J., Harrast, M., Adami, P. E., Bermon, S., Bigard, X., Migliorini, S., Jordaan, E., Borjesson, M.

Journal Article

Mass participation endurance sports events are popular but a large number of participants are older and may be at risk of medical complications during events. Medical encounters (defined fully in the statement) include those traditionally considered ‘musculoskeletal’ (eg, strains) and those due to ‘illness’ (eg, cardiac, respiratory, endocrine). The rate of sudden death during mass endurance events (running, cycling and triathlon) is between 0.4 and 3.3 per 100 000 entrants. The rate of other serious medical encounters (eg, exertional heat stroke, hyponatraemia) is rarely reported; in runners it can be up to 100 times higher than that of sudden death, that is, between 16 and 155 per 100 000 race entrants. This consensus statement has two goals. It (1) defines terms for injury and illness-related medical encounters, severity and timing of medical encounters, and diagnostic categories of medical encounters, and (2) describes the methods for recording data at mass participation endurance sports events and reporting results to authorities and for publication. This unifying consensus statement will allow data from various events to be compared and aggregated. This will inform athlete/patient management, and thus make endurance events safer.

Injury epidemiology and risk factors in competitive artistic gymnasts: a systematic review

19-08-2019 – Campbell, R. A., Bradshaw, E. J., Ball, N. B., Pease, D. L., Spratford, W.

Journal Article, Review

Background
Artistic gymnastics is reported to have some of the highest injury rates in sports, which limits participation and often involves considerable medical expenses.
Purpose
To critically appraise the epidemiological literature on injury patterns and risk factors in competitive artistic gymnastics.
Study design
Systematic review.
Methods
Six databases were searched for articles that investigated injuries in competitive artistic gymnasts. Injury incidence, prevalence and risk factor data were extracted, alongside information on injury location, type, severity, nature and mechanism of injury. Quality and level of evidence were assessed using a modified Downs and Black quality index checklist and the Oxford Centre for Evidence-based Medicine guidelines.
Results
The search identified 894 articles, with 22 eligible for inclusion. Descriptive analysis showed that injury incidence and prevalence varied from 0.3 to 3.6 injuries per gymnast (female=0.3–3.6, male=0.7) and 2.0–2.3 (female=2.0–2.3, male=2.0), respectively. Male gymnasts sustained mostly upper limb injuries, while female gymnast reported lower limb injuries. Floor was associated with the greatest number of injuries for both male and female gymnasts. Higher competitive level and exposure to competition were risk factors for gymnastics injury: age, body mass, body size, training duration and life stress were significant associated factors.
Conclusion
Injury incidence and prevalence results are substantial among artistic gymnasts of all competitive levels. Gymnasts who train at highly competitive levels and are exposed to competition environments are a greater risk of injury. Future researchers should implement consistent reporting methods.

Efficacy of heavy eccentric calf training for treating mid-portion Achilles tendinopathy: a systematic review and meta-analysis

19-08-2019 – Murphy, M. C., Travers, M. J., Chivers, P., Debenham, J. R., Docking, S. I., Rio, E. K., Gibson, W.

Journal Article, Review

Objective
To assess the effectiveness of heavy eccentric calf training (HECT) in comparison with natural history, traditional physiotherapy, sham interventions or other exercise interventions for improvements in pain and function in mid-portion Achilles tendinopathy.
Design
A systematic review and meta-analysis were conducted as per the PRISMA guidelines.
Data sources
PUBMED, CINAHL (Ovid) and CINAHL (EBSCO) were searched from inception until 24 September 2018.
Eligibility criteria
Randomised controlled trials comparing HECT to natural history, sham exercise, traditional physiotherapy and other exercise interventions were included. Primary outcome assessing pain and function was the Victorian Institute of Sports Assessment-Achilles.
Results
Seven studies met the inclusion criteria. This review suggests HECT may be superior to both natural history, mean difference (MD) (95% CI) of 20.6 (11.7 to 29.5, one study) and traditional physiotherapy, MD (95% CI) of 17.70 (3.75 to 31.66, two studies). Following removal of one study, at high risk of bias, due to pre-planned sensitivity analysis, this review suggests HECT may be inferior to other exercise interventions, MD (95% CI) of –5.65 (-10.51 to –0.79, three studies). However, this difference is unlikely to be clinically significant.
Conclusion
Current evidence suggests that HECT may be superior to natural history and traditional physiotherapy while HECT may be inferior to other exercise interventions. However, due to methodological limitations, small sample size and a lack of data we are unable to be confident in the results of the estimate of the effect, as the true effect is likely to be substantially different.
Systematic review registry
PROSPERO registration number: CRD4201804493Protocol reference
This protocol has been published open access: Murphy M, Travers MJ, Gibson, W. Is heavy eccentric calf training superior to natural history, sham rehabilitation, traditional physiotherapy and other exercise interventions for pain and function in mid-portion Achilles tendinopathy? Systematic Reviews 2018; 7: 58

How cold is too cold? Establishing the minimum water temperature limits for marathon swim racing

19-08-2019 – Saycell, J., Lomax, M., Massey, H., Tipton, M.

Journal Article

Objectives
To provide a rationale for minimum water temperature rules for elite and subelite marathon swim racing and highlight factors that make individuals vulnerable to excessive cooling during open water swimming.
Methods12 lean competitive swimmers swam for up to 2 hours, three times in different water temperatures between 14°C and 20°C, wearing standard swimming costumes and hats. Rectal temperature (Tre), oxygen consumption, perception of cold and performance were measured.
Results
In 16°C, half the swimmers did not complete a 2-hour swim; four became (or were predicted to become) hypothermic within 2 hours. In 18°C, three-quarters completed the swim; three became (or were predicted to become) hypothermic. In 20°C, one swimmer was predicted to become hypothermic in under 2 hours. The mean linear rate of fall of Tre was greater in 16°C (–1.57°C/hour) than 18°C (–1.07°C/hour) (p=0.03). There was no change in swimming performance during the swims or between conditions. Most of the cooling rate could be explained by metabolic heat production and morphology for both 16°C (R2=0.94, p<0.01) and 18°C (R2=0.82, p<0.01) conditions. No relationship was observed between Tre and perception of thermal sensation (r=0.25, p=0.13), and there was a weak correlation between Tre and thermal comfort (r=0.32, p=0.04).
Conclusion
We recommend that 16°C and 18°C water are too cold for elite marathon swim racing. Fédération
Internationale de Natation rules were changed in 2017 to make wetsuits compulsory below 18°C and optional below 20°C.

Sports injury and illness incidence in the PyeongChang 2018 Olympic Winter Games: a prospective study of 2914 athletes from 92 countries

19-08-2019 – Soligard, T., Palmer, D., Steffen, K., Lopes, A. D., Grant, M.-E., Kim, D., Lee, S. Y., Salmina, N., Toresdahl, B. G., Chang, J. Y., Budgett, R., Engebretsen, L.

Journal Article

Objective
To describe the incidence of injuries and illnesses sustained during the XXIII Olympic Winter Games, hosted by Pyeong
Chang on 9–25 February 2018.
Methods
We recorded the daily number of athlete injuries and illnesses (1) through the reporting of all National Olympic Committee (NOC) medical teams and (2) in the polyclinic and medical venues by the Pyeong
Chang 2018 medical staff.
Results
In total, 2914 athletes (1210 women, 42%; 1704 men, 58%) from 92 NOCs were observed for occurrence of injury and illness. NOC and Pyeong
Chang 2018 medical staff reported 376 injuries and 279 illnesses, equalling 12.6 injuries and 9.4 illnesses per 100 athletes over the 17-day period. Altogether, 12% of the athletes incurred at least one injury and 9% at least one illness. The injury incidence was highest in ski halfpipe (28%), snowboard cross (26%), ski cross (25%), snowboard slopestyle (21%) and aerials (20%), and lowest in Nordic combined, biathlon, snowboard slalom, moguls and cross-country skiing (2%–6%). Of the 376 injuries recorded, 33% and 13% were estimated to lead to ≥1 day and >7 days of absence from sport, respectively. The highest incidences of illness were recorded in biathlon (15%), curling (14%), bobsleigh (14%) and snowboard slalom (13%). Thirty per cent of the illnesses were expected to result in time loss, and 70% affected the respiratory system. Women suffered 61% more illnesses than men.
Conclusion
Overall, 12% of the athletes incurred at least one injury during the Games and 9% an illness, incidences that are similar to the Olympic Winter Games of 2010 and 2014.

Common cold in Team Finland during 2018 Winter Olympic Games (PyeongChang): epidemiology, diagnosis including molecular point-of-care testing (POCT) and treatment

19-08-2019 – Valtonen, M., Waris, M., Vuorinen, T., Eerola, E., Hakanen, A. J., Mjosund, K., Grönroos, W., Heinonen, O. J., Ruuskanen, O.

Journal Article

Objectives
The common cold is the main cause of medical time loss in elite sport. Rapid diagnosis has been a challenge that may be amenable to molecular point-of-care testing (POCT).
Methods
We performed a prospective observational study of the common cold in Team Finland during the 2018 Winter Olympic Games. There were 44 elite athletes and 68 staff members. The chief physician recorded the symptoms of the common cold daily on a standardised form. Two nasal swabs were taken at the onset of symptoms. One swab was analysed within 45 min using a molecular POCT for respiratory syncytial virus and influenza A and B viruses. After the Games, the other swab was tested for 16 possible causative respiratory viruses using PCR in laboratory-based testing.
Results20 out of 44 (45%) athletes and 22 out of 68 (32%) staff members experienced symptoms of the common cold during a median stay of 21 days. Eleven (26%) samples tested virus-positive using POCT. All subjects with influenza (n=6) and 32 close contacts were treated with oseltamivir. The aetiology of the common cold was finally detected in 75% of the athletes and 68 % of the staff members. Seven virus clusters were identified. They were caused by coronaviruses 229E, NL63 and OC43, influenza B virus, respiratory syncytial virus A, rhinovirus and human metapneumovirus. The virus infections spread readily within the team, most commonly within the same sport discipline.
Conclusions
The cold was indeed a common illness in Team Finland during the Winter Olympic Games. POCT proved to be clinically valuable, especially for influenza. The aetiology of the common cold was identified in most cases.

Incidence rate and burden of illness at the Pyeongchang 2018 Paralympic Winter Games

19-08-2019 – Derman, W., Runciman, P., Jordaan, E., Schwellnus, M., Blauwet, C., Webborn, N., Lexell, J., van de Vliet, P., Kissick, J., Stomphorst, J., Lee, Y.-H., Kim, K.-S.

Journal Article

Objective
To describe the incidence rate (IR) and illness burden (IB) at the Pyeongchang 2018 Paralympic Winter Games.
Methods
A total of 567 athletes from 49 countries were monitored for 12 days over the Pyeongchang 2018 Games (6804 athlete days). Illness data were obtained daily from teams with (41 teams, 557 athletes) and teams without (8 teams, 10 athletes) their own medical support, through electronic data capturing systems.
Results
There were 87 illnesses reported, with an illness IR of 12.8 illnesses per 1000 athlete days (95% CI 10.2 to 16.0) and IB of 6.8 days lost per 1000 athlete days (95% CI 3.4 to 13.5). The highest IR was reported for Para snowboard (IR of 19.7 95% CI 12.0 to 32.2). Illnesses in the respiratory system (IR of 4.1 95% CI 2.9 to 5.9; IB of 1.4 95% CI 0.6 to 3.0), skin and subcutaneous system (IR of 2.5 95% CI 1.5 to 4.1; IB of 0.6 95% CI 0.1 to 2.9), and eye and ocular adnexa (IR of 1.6 95% CI 0.9 to 3.1; IB of 0.5 95% CI 0.1 to 3.3) were the most common.
Conclusion
This is the first study to report both the IR and IB in this setting. There was a high IR of illness in the new sport of Para snowboard. The respiratory system had both the highest IR and IB.

Pharmacy services at the PyeongChang 2018 Olympic and Paralympic Winter Games

19-08-2019 – Stuart, M., Kwon, Y. I., Rhie, S. J.

Journal Article

Objective
Pharmacy services at large multisport events support safe and effective medication use. Our aim is to describe the contribution of pharmacists and to share the pharmacy experiences at the 2018 Pyeong
Chang Olympic and Paralympic Games.
Methods
The data collected included the accreditation details of patients and prescribers indicating: sport, country, athlete or non-athlete status, and prescription details including: medication, strength, frequency, length of treatment, for the period of the Olympic Games (1–26 February 2018) and the Paralympic Games (5–20 March 2018). The numbers of prescriptions dispensed were analysed by medication category, sports and country of the patient.
Results
A total of 5313 medication items were dispensed over the course of the Olympic and Paralympic Games (athletes: 670; non-athletes: 4615; unknown: 28), for a total of 2360 patients. 72 of 82 countries (87.8%) had fewer than 20 patient visits. The first high peak (Olympic: 5.0%; Paralympic: 7.3%) of daily volume of prescriptions were dispensed in the 2 days prior to the Olympic and the 1 day prior to Paralympic opening ceremonies. Therapeutic Use Exemption (TUE) and International Olympic Committee Needle
Policy were well managed and compliant with the regulations.
Conclusion
Pharmacy services at major multisport games include dispensing over 5000 prescriptions, supporting the TUE and IOC Needle Policy processes and providing clinical information to athletes and prescribers on drugs in sports and the World Anti-Doping Agency regulations of drugs prohibited in sport. During the Pyeong
Chang 2018 Olympic and Paralympic Winter Games, pharmacists played a crucial role in delivering safe and effective pharmacy service based on their expert knowledge in antidoping and the clinical use of drugs in sport.

Pre-participation health evaluation in adolescent athletes competing at Youth Olympic Games: proposal for a tailored protocol

19-08-2019 – Adami, P. E., Squeo, M. R., Quattrini, F. M., Di Paolo, F. M., Pisicchio, C., Di Giacinto, B., Lemme, E., Maestrini, V., Pelliccia, A.

Journal Article

Objective
To promote sports participation in young people, the International Olympic Committee (IOC) introduced the Youth Olympic Games (YOG) in 2007. In 2009, the IOC Consensus Statement was published, which highlighted the value of periodic health evaluation in elite athletes. The objective of this study was to assess the efficacy of a comprehensive protocol for illness and injury detection, tailored for adolescent athletes participating in Summer or Winter YOG.
Methods
Between 2010 and 2014, a total of 247 unique adolescent elite Italian athletes (53% females), mean age 16±1,0 years, competing in 22 summer or 15 winter sport disciplines, were evaluated through a tailored pre-participation health evaluation protocol, at the Sports Medicine and Science Institute of the Italian Olympic Committee.
Results
In 30 of the 247 athletes (12%), the pre-participation evaluation led to the final diagnosis of pathological conditions warranting treatment and/or surveillance, including cardiovascular in 11 (4.5%), pulmonary in 11 (4.5%), endocrine in five (2.0%), infectious, neurological and psychiatric disorders in one each (0.4%). Based on National and International Guidelines and Recommendations, none of the athletes was considered at high risk for acute events and all were judged eligible to compete at the YOG. Athletes with abnormal conditions were required to undergo a periodic follow-up.
Conclusions
The Youth Pre-Participation Health Evaluation proved to be effective in identifying a wide range of disorders, allowing prompt treatment, appropriate surveillance and avoidance of potential long-term consequences, in a significant proportion (12%) of adolescent Italian Olympic athletes.

Health promotion by International Olympic Sport Federations: priorities and barriers

19-08-2019 – Mountjoy, M., Junge, A., Budgett, R., Doerr, D., Leglise, M., Miller, S., Moran, J., Foster, J.

Journal Article

Objective
To identify changes in International Federations’ priorities and the barriers to implementing athlete and global health initiatives. Results should influence the work of the International Federation medical committees, the IOC and the Association of Summer Olympic International Federation.
Methods
The 28 Summer and 7 Winter International Federations participating in the most recent Olympic Games (2016; 2018) were surveyed to (i) identify the importance of 27 health topics, (ii) assess their progress on implementation health-related programmes and (iii) the barriers to implementation of these programmes. We compared International Federations’ activities in 2016 and 2017.
Results
The response rate was 83%. Health topics which most International Federations regarded as important and in which the International Federations felt insufficiently active were ‘team physician certification’, ‘prevention of harassment and abuse’, ‘eating disorders/disordered eating’, ‘mental health’ and ‘injury surveillance’. Compared with 2016, there was a decrease in International Federations’ activities in ‘injury surveillance’, ‘nutritional supplements’ and ‘hyperandrogenism’. The main barrier to implementing health-related programmes was ‘International Federation political support/willingness’, followed by ‘knowledge’. ‘Time’ and ‘coach support’ were more often reported than ‘finances’, or ‘IOC or Association of Summer Olympic International Federations partnership’.
Conclusion
If International Federations are going to promote health of athletes and global health promotion through physical activity (sport), International Federation leadership must change their focus and provide greater political support for related initiatives. Improving coach and athlete knowledge of the health issues could also facilitate health programme delivery. Time constraints could be mitigated by sharing experiences among the International Federations, Association of Summer Olympic International Federations and the IOC. International Federations should focus on those health-related topics that they identified as being important, yet rate as having insufficient activity.

Why not consider a sex factor within the ISO 11088 ski binding setting standard?

19-08-2019 – Ruedl, G., Burtscher, M.

In recreational alpine skiing, about one-third of all injuries are related to the knee joint.1 However, female recreational skiers have twice the knee injury incidence of male skiers and the ACL injury risk is even three times higher in female skiers.1 A total of 60%–80% of knee injuries after a self-inflicted fall seem to be associated with a failure of binding release and again with decisive sex differences.1 Female skiers reported about 20% more often failure of binding release than men.1 In an epidemiological study including more than 1300 injured recreational skiers, self-reported failure of binding release was significantly higher in women when compared with men (51% vs 32%), irrespective of the injured body part.2 Noteworthy, among uninjured skiers, three times more women were unable to release their ski bindings during a self-release test even though their bindings were…